Page 6 - 2018 Movilitas Benefit Guide
P. 6
Medical Benefits
You have the option of choosing between two traditional PPO plans and one HSA qualiied high deductible
health plan (HDHP).
BCBS of IL BCBS of IL BCBS of IL
$750 Ded PPO Copay Plan $1,500 Ded PPO Copay Plan $3,000 Ded Qualiied HDHP
In-Network In-Network In-Network
Dependent Eligibility Children covered up to age 26 regardless of marital, student, or dependency status
Lifetime Maximum Unlimited
Calendar Year Deductible Embedded—no one individual Not embedded—family Embedded—no one individual
must meet more than the ded applies if one or more must meet more than the
individual limit dependents are covered individual limit
Individual $750 $1,500 $3,000
Family $1,500 $3,000 $6,000
Out-of-Pocket Maximum Embedded—out-of-pocket Not embedded—family out- Embedded—out-of-pocket
maximum includes deductible, of-pocket maximum applies if maximum includes deductible
coinsurance, and medical one or more dependents are and coinsurance
copays covered
Individual $3,000 $4,000 $3,000
Family $6,000 $8,000 $6,000
Physician Ofice Visits
Primary Care $20 copay* $25 copay* 100% after ded
Specialist $40 copay* $50 copay* 100% after ded
Urgent Care Ded/80% Ded/80% 100% after ded
Wellness/Preventive Covered at 100% Covered at 100% Covered at 100%
Lab Services
Physicians Ofice Covered at 100%** Covered at 100%** 100% after ded
Outpatient Facility Covered at 100%** Covered at 100%** 100% after ded
Outpatient Hospital Covered at 100%** Covered at 100%** 100% after ded
X-Ray/Radiology Services
Physicians Ofice Covered at 100%** Covered at 100%** 100% after ded
Outpatient Facility Covered at 100%** Covered at 100%** 100% after ded
Outpatient Hospital Covered at 100%* Covered at 100%** 100% after ded
Hospital Services
Inpatient 80% after ded 80% after ded 100% after ded
Outpatient 80% after ded 80% after ded 100% after ded
Emergency Room $150 copay $250 copay 100% after ded
Ambulance 80% after ded 80% after ded 100% after ded
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100%. All other services
are subject to ded/coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans, etc.),
nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance.
6 2018 Benefits Enrollment
You have the option of choosing between two traditional PPO plans and one HSA qualiied high deductible
health plan (HDHP).
BCBS of IL BCBS of IL BCBS of IL
$750 Ded PPO Copay Plan $1,500 Ded PPO Copay Plan $3,000 Ded Qualiied HDHP
In-Network In-Network In-Network
Dependent Eligibility Children covered up to age 26 regardless of marital, student, or dependency status
Lifetime Maximum Unlimited
Calendar Year Deductible Embedded—no one individual Not embedded—family Embedded—no one individual
must meet more than the ded applies if one or more must meet more than the
individual limit dependents are covered individual limit
Individual $750 $1,500 $3,000
Family $1,500 $3,000 $6,000
Out-of-Pocket Maximum Embedded—out-of-pocket Not embedded—family out- Embedded—out-of-pocket
maximum includes deductible, of-pocket maximum applies if maximum includes deductible
coinsurance, and medical one or more dependents are and coinsurance
copays covered
Individual $3,000 $4,000 $3,000
Family $6,000 $8,000 $6,000
Physician Ofice Visits
Primary Care $20 copay* $25 copay* 100% after ded
Specialist $40 copay* $50 copay* 100% after ded
Urgent Care Ded/80% Ded/80% 100% after ded
Wellness/Preventive Covered at 100% Covered at 100% Covered at 100%
Lab Services
Physicians Ofice Covered at 100%** Covered at 100%** 100% after ded
Outpatient Facility Covered at 100%** Covered at 100%** 100% after ded
Outpatient Hospital Covered at 100%** Covered at 100%** 100% after ded
X-Ray/Radiology Services
Physicians Ofice Covered at 100%** Covered at 100%** 100% after ded
Outpatient Facility Covered at 100%** Covered at 100%** 100% after ded
Outpatient Hospital Covered at 100%* Covered at 100%** 100% after ded
Hospital Services
Inpatient 80% after ded 80% after ded 100% after ded
Outpatient 80% after ded 80% after ded 100% after ded
Emergency Room $150 copay $250 copay 100% after ded
Ambulance 80% after ded 80% after ded 100% after ded
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100%. All other services
are subject to ded/coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans, etc.),
nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance.
6 2018 Benefits Enrollment
